The SAGES Atlas of Robotic Surgery

By Yuman Fong

This book is intended as a definitive, state of the art guide to robotic surgery that summarizes the field for surgeons at all levels. More specifically, its goals are threefold: to review the basics of robotic surgery, including fundamental principles, technology, operating room setup, and workflow; to describe and illustrate the procedures most commonly performed in a robotic operating room; and to discuss key issues relating to cost, adoption, and training. Procedures from many surgical disciplines are included, which will aid robotic surgeons in supervising and assisting colleagues in these disciplines and simultaneously heighten their awareness of the tricks and tools used in other disciplines that can be retasked for their own purposes. In addition, the future prospects for robotic surgery, including anticipated developments in equipment, are discussed. The Textbook and Atlas of Robotic Surgery will be an excellent aid for residents and fellows entering the field, as well as a welcome update on recent progress for practicing robotic surgeons and an ideal primer for senior surgeons adapting these new technologies to their current practice.

• Language: English
• Publisher: Springer
• Release date: Sep 8, 2018
• ISBN: 9783319910451

Book preview

Part IHistory and Basics of Robotic Surgery

© Springer International Publishing AG, part of Springer Nature 2018

Yuman Fong, Yanghee Woo, Woo Jin Hyung, Clayton Lau and Vivian E. Strong (eds.)The SAGES Atlas of Robotic Surgeryhttps://doi.org/10.1007/978-3-319-91045-1_1

1. History of Robots and Robotic Surgery

Paolo Fiorini¹  

(1)

Department of Computer Science, University of Verona, Verona, Italy

Paolo Fiorini

Email: [e-mail]

Keywords

RoboticsRobot-assisted surgeryHistory of robotics

Introduction

This chapter presents a brief history of robotics and one of its most successful applications, surgical robotics. The first section describes the beginning of this technology, from 1950 to 1980, when the basic concepts and technologies were developed. The second section addresses the development of robotic surgery, which has established itself as a necessary complement to standard surgical practice. The third section briefly summarizes some of the current research efforts in robotic surgery, and the fourth section introduces the main commercial surgical robots available on the market. The final section describes the most important robotic concepts that are necessary to understand the main features of any surgical robot.

The Beginnings

Robots are among the good byproducts of the Second World War. Their technology derived from the early teleoperation systems developed in 1948 by Raymond Goertz at the Argonne National Laboratory in the United States, to handle radioactive material [1]. The word robot and the concept of a mechanical entity able to carry out tasks that a person cannot do or does not want to do pre-date this technology development. The word robot started to be used in the 1920s following a play by the Czech author Karel Capek, called R.U.R. (Rossum’s Universal Robots), in which artificial biological organisms in human form obey their master’s orders [2]. These organisms were called robots, a word derived from the Czech robota, meaning forced labor. They were more similar to androids than to current humanoid robots, as they could also think for themselves, which eventually led to a rebellion that destroyed the human race. The word robot then came to identify all devices developed to display an animate behavior.

In ancient times, many mythological figures and brilliant devices have been described that mimic human or animal functions. It is worth remembering the clay golems of Jewish legend [3], the clay giants of Norse legend, and the Greek myth of Talos [4], in which a bronze warrior guarded the island of Crete in 400 BC. The quest to develop mechanical humans is present in most cultures. In early China, about 900 BC, the inventor Yan Shi developed for King Mu of Zhou a life-sized, human-shaped figure made of leather and wood [5]. In 1066, the Chinese inventor Su Song built a water clock shaped as a tower with mechanical figures indicating the hours [6]. About 1495 in Italy, Leonardo da Vinci drew in his notebooks the plans for a mechanical knight able to sit up, wave its arms, and move its head and jaw [7]. In Japan, complex animal and human automata were built in the seventeenth to nineteenth centuries [8], such as the karakuri ningyō, a type of mechanical device used to recreate different events, such as the tea ceremony. In France, between 1738 and 1739, Jacques de Vaucanson developed several life-sized automatons, including his famous mechanical duck, which could flap its wings, move its neck, swallow food, and give the illusion of digesting it by excreting matter stored in its body [9]. To impress the Empress Maria Theresa of Austria, in 1770 the Hungarian inventor Kempelen Farkas developed a mechanism that was unbeatable at chess. The machine was called the Mechanical Turk; only in 1820 was it exposed as a hoax, with a person hidden inside the structure [10].

The word robotics has also a nontechnical origin. It was created in the 1940s by the Russian writer Isaac Asimov to represent the study of mechanical robots of human appearance. The robots’ behavior was programmed in a positronic brain and satisfied certain rules of ethical conduct, which came to be known as the Three Laws of Robotics [11].

The first teleoperation system credited to Raymond Goertz consisted of a master device, held by the operator, and by a slave mechanical arm, in contact with the environment, in the so-called master-slave configuration. The slave was coupled to the master through a series of mechanical linkages, and it duplicated the motions of the operator’s hands and fingers. These linkages were eventually replaced by electric or hydraulic coupling; the operator could then control the position of the slave arms but lost the perception of contacts provided by the mechanical linkages. Force feedback was then added to the teleoperation system to prevent crushing glass containers, and the operator could again feel the interaction forces of the slave with the environment. This solution was called teleoperator to represent a teleoperation system that was not mechanically linked with the operator. The term telepresence was also introduced to describe the added sensory feedback, from the remote environment to the operator, who thus has increased sensory and decision-making abilities.

In 1949, the US Air Force sponsored the development of numerically controlled milling machines [12] that combined servo systems with the newly developed numerical computers. In 1953, the MIT Radiation Laboratory demonstrated the prototype of a computer numerically controlled (CNC) machine . In 1954, George Devol replaced the master device of the teleoperator with the computer control of a CNC machine and called this device a programmed articulated transfer device for which he filed a patent [13]. The patent rights were bought by a Columbia University student, Joseph Engelberger, who founded a company called Unimation in 1956. In 1960, the first Unimation robot was demonstrated, and the first installation was done the following year at a General Motors plant. This industrial robot could be reprogrammed to perform different pick-and-place tasks, but all parts needed to be accurately positioned in the working cell, as the robot could not adapt to any position error [14]. The first applications were for material handling in steel plants. To overcome the need for precise part positioning, in 1961 a robot with force sensing was developed at MIT [15], which enabled the robot to stack blocks in an unstructured environment without explicitly programming the robot motions. Other sensors were added to robots to increase the perception of their environment. In the 1960s, binary and halftone vision systems were also developed for obstacle detection [16], followed later by a camera vision system [17]. One of the most influential early designs was the Stanford arm designed in 1969 by Victor Scheinman at the Stanford Artificial Intelligence Lab (SAIL) (Fig. 1.1). It was a six-joint, all-electric mechanical manipulator designed exclusively for computer control [18].

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Fig. 1.1

The Stanford Arm (courtesy of Prof. Oussama Khatib, Stanford University)

This robot was enhanced with artificial intelligence algorithms that enabled it to solve puzzles [19]. These sensor-equipped robots were able to perform tasks requiring the control of the interaction forces with the environment. Japanese researchers developed the automatic selection of force and position control, and this led to the development of a mechanical manipulator with compliance control [20]. Roughly at the same time, in 1973, Stanford researchers developed the first language for programming a robot [21]. The first anthropomorphic industrial robot was developed in 1976 by Cincinnati Milacron Inc. The Tomorrow Tool (T3) could lift 50 kg and track objects on a moving conveyor belt [22]. In 1973, Victor Scheinman developed the Vicarm , which was sold in 1977 to Unimation. Figure 1.2 shows the brochure of the robots produced by Scheinman company. The following year, with support from General Motors, Unimation developed the Vicarm into the PUMA (Programmable Universal Machine for Assembly) family of robots, which would become the workhorse of robotics research (Figs. 1.3 and 1.4). In the mid-1970s, Antal Bejczy at Caltech NASA-Jet Propulsion Laboratory (JPL) developed the first dynamic model of a robotic arm and later began the teleoperation program for space-based manipulators, which led to robotic surgery. In 1979, the SCARA (Selective Compliant Articulated Robot for Assembly ) was developed. Based on these results, the group of Antal Bejczy developed the Advanced Teleoperation Laboratory to demonstrate the feasibility of space repair from Earth and developed some of the technologies for bilateral teleoperation used in later telesurgical systems (Figs. 1.5 and 1.6).

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Fig. 1.2

Brochure of Vicarm, the first manufacturer of commercial robots (courtesy of Prof. Paolo Fiorini, University of Verona)

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Fig. 1.3

The Puma 500 robotic arm (courtesy of Prof. Paolo Fiorini, University of Verona)

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Fig. 1.4

The Puma 200 robotic arm (courtesy of Prof. Paolo Fiorini, University of Verona)

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Fig. 1.5

The master station of the Advanced Teleoperation Laboratory at NASA-JPL (courtesy of NASA/JPL-Caltech)

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Fig. 1.6

The slave station of the Advanced Teleoperation Laboratory at NASA-JPL (courtesy of NASA/JPL-Caltech)

The introduction of force and touch sensing raised the attention of the medical community, and in 1963 researchers at the Institute Mihajlo Pupin in Belgrade developed the first robotic prosthetic device capable of programmed grasping patterns, later known as the Belgrade hand [23]. Shortly afterward, in 1972, the same Institute developed a powered exoskeleton, one of the first assistive devices for walking disabilities. Papers on robotic research carried out by scientists at the Institute Mihajlo Pupin started to appear in the western press in 1973 [24], together with the results of Russian scientists [25]. English editions of books summarizing the results achieved by the Russian robotics community [26] and books reporting on the activities of the Pupin Institute [27] were published shortly afterward.

The other important player in the early days of robotics and teleoperation research was the Paris laboratory of CEA (the French Commissariat à l’énergie atomique et aux énergies alternatives), where Jean Vertut established his laboratory in 1962. The other leading French laboratory in robotics was the Laboratory for Automation and Microprocessing, Monipellier (LAMM), led by Philippe Coiffet. Both laboratories are still very active in teleoperation and robotic research. These early developments and the results achieved by the French robotics community are well documented in several books [28].

In the 1920s, robots began appearing in department stores in Japan under the shape of a humanoid robot named Gakutensoku. Later, the robotic idea was carried on by the cartoon character Astro Boy, a manga series running from 1952 to 1968 [29]. Industrial robots made their appearance in Japan through Kawasaki’s acquisition of a license from Unimation in 1968. In 1972, researchers were able to program a robot to build a block structure after examining the drawings of a final configuration [30]. The following year, researchers at the Waseda University in Tokyo developed the WABOT-1, a full-scale humanoid robot with two arms, capable of walking on two legs and seeing with stereo cameras [31]. The introduction of new force sensors prompted the development of efficient algorithms for the control of dynamic interactions between the robot and its environment, such as the automatic turning of a crank [32].

The 1980s saw the development of many robotic products for industrial automation, and of new algorithms to improve robot speed and position accuracy, leading to an in-depth understanding of the capabilities and limitations of robotic systems, identifying promising applications. During this period, robotics became a recognized field of research with regular conferences and scientific publications. Research results were initially reported by two international organizations, the American Nuclear Society and the International Federation for Theory of Machines and Mechanisms (IFToMM), which started organizing at the Centre International des Sciences Mecaniques (CISM, Udine, Italy) the Robot and Manipulator Symposiums (RO.​MAN.​SY), still an important forum for today’s robotics community. Later, also other major robotics conferences began to be organized: the International Conference on Advanced Robotics (ICAR), the IEEE International Conference on Automation and Robotics (ICRA), and the International Conference on Intelligent Robotic Systems (IROS).

The Development of Surgical Robotics

Together with the development of basic robotic technologies, researchers started considering the use of robots in areas in which human performance could be improved [33, 34]. The idea of robotic surgery was probably born in the early 1970s, proposed in a study for the National Aeronautics and Space Administration (NASA) to provide surgical care for astronauts with remote-controlled robots [35].

The first robot that was designed for patient treatment was the Arthrobot in 1983, for arthroscopic procedures. The development was led by J. McEwen, G. Auchinlec, and B. Day at the University of British Columbia, Canada [36]; the first procedures were carried out in 1984. At the same time, experiments were carried out in California of robot-assisted stereotaxic brain surgery. A joint team from Memorial Medical Center in Long Beach and NASA-JPL led by Y. S. Kwoh and Samad Hayati used a Puma 200 to hold and manipulate a biopsy cannula, navigated by a stereotactic frame mounted on the base of the robot [37]. In the same period, similar interventions were also performed in China.

In the late 1980s, the idea of robot-assisted minimally invasive telesurgery was primarily developed under the leadership of Richard Satava within the US Army, which funded SRI International’s development of a prototype telesurgical system [38]. The prototype was demonstrated in animal experiments, described by Bowersox et al. [39]. Contemporary to the US development, at the University of Karlsruhe (Germany), the team led by Gerhard Buess, already a pioneer of endoscopic surgery, developed (together with the Nuclear Research Center in Karlsruhe) the surgical robot prototype ARTEMIS , with seven degrees of freedom (DoF) [40, 41], shown in Fig. 1.7.

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Fig. 1.7

The master station of the ARTEMIS surgical robot (courtesy of Prof. Alberto Arezzo, University of Torino)

In the mid-1980s, Brian Davies and his team at Imperial College (London, UK) started to work on prostate surgery and developed the system called PROBOT for transurethral resection of the prostate (TURP) procedures in 1991 [42]. In Milano, the team lead by Alberto Rovetta also developed a robot for TURP, which was used in a clinical trial [43].

The first robotic system for orthopedic surgery was developed in 1986 by a team formed by two surgeons, Dr. Howard Paul and Dr. William Bargar, and researchers at IBM Watson Research Center (Yorktown Heights, NY) led by Russell Taylor. This system was further developed by Integrated Surgical Systems (ISS, Santa Monica, CA), which in 1992 created the first orthopedic surgical system, in collaboration with the University of California–Davis. This system was called ROBODOC and was used for robot-assisted human hip replacement [44]. The team at Imperial College also addressed orthopedic surgery and developed the Acrobot® system for total knee replacement procedures [45]. Other robots developed for orthopedic surgery were CRIGOS [46] and Orto Maquet CASPAR [47].

In 1989, Yulan Wang founded Computer Motion Inc. (Goleta, CA), and, with a NASA-JPL grant, in 1992 he developed a robotic system able to move an endoscope during laparoscopic surgeries. He then commercialized this device as the Automated Endoscopic System for Optimal Positioning (AESOP), the first commercial robot to be routinely used in the operating room [48]. The AESOP system was later extended with the addition of more arms and different surgical instruments, and it became the Zeus Robotic Surgical System (Fig. 1.8), which included three arms [49].

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Fig. 1.8

The Zeus surgical robotic system (courtesy of Prof. Guang-Zhong Yang, The Hamlyn Center, Imperial College)

A collaboration between the ophthalmic surgeon Steve Charles and the NASA-JPL team of Antal Bejczy led to the development by Hari Nayar of the Advanced Teleoperation (ATOP) Lab of the robot-assisted microsurgery (RAMS) system in 1994, a robotic system for microsurgery with force feedback (Fig. 1.9) [50]. The RAMS capabilities were later demonstrated in coronary artery anastomoses on animals [51].

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Fig. 1.9

The robot-assisted microsurgery system (courtesy of NASA/JPL-Caltech)

Intuitive Surgical Inc. (Mountain View, CA) was founded in 1995 by Frederic Moll. After acquiring some of the patents of SRI for their surgical robotic system, Intuitive Surgical created a first prototype of the da Vinci surgical system in 1997 to carry out clinical trials, which led to the first closed-chest, multivessel cardiac bypass procedure in 1999. The da Vinci system was cleared by the US Food and Drug Administration (FDA) for human use in 2000 and commercialized as shown in Fig. 1.10. After several attempts to create a market for beating-heart procedures, the da Vinci system found its niche in urology and gynecology, where it is now the gold standard for intervention. After a long patent dispute, Intuitive Surgical acquired Computer Motion, its only competitor, in 2003, and shortly afterward it discontinued the production of the Zeus system [52].

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Fig. 1.10

The first generation of the da Vinci Surgical System (courtesy of Prof. Guang-Zhong Yang, The Hamlyn Center, Imperial College)

There have also been a few attempts at long-distance telesurgery. The first experiment was performed in 1993 between NASA-JPL (Pasadena, CA) and Milan, Italy, by the teams of Antal Bejczy and Alberto Rovetta [53]. A few years later, Jacques Marescaux performed a cholecystectomy on a patient in Strasbourg (France) from New York, controlling a Zeus robot in France [54]. The Zeus robot was also involved in the 2004 NEEMO experiments of undersea simulated surgery controlled remotely from the Centre for Minimal Access Surgery, London, UK. In 2005, the US Department of Defense launched its long-distance medical assistance project, the Trauma Pod [55], to demonstrate the feasibility of the original idea of Richard Satava, an emergency surgical unit in combat areas [56]. Although all these experiments were successful, long-distance telesurgery has not yet entered clinical practice because of safety and certification issues.

Several robots were also developed for neurosurgery. In 1997, the team of Alim Louis Benabid in Grenoble developed the NeuroMate system [57], a stereotaxic targeting device for neurosurgery, which was the first neurosurgical robot to receive FDA clearance. This robot was initially marketed by Innovative Medical Machines International (Lyon, France) and now is a Renishaw product [58]. Minerva [59] was designed for stereotactic brain biopsy to meet specifications incorporating safety and geometry, to perform single-dimensional incursions into the brain while the patient is within a CT system that continuously provides real-time imaging data to the robot. The PathFinder was an image-guided, frameless, six-axes robot to accurately position a tool for neurosurgery [60].

Development Directions in Surgical Robotics

Robotic surgery is a very active area of research, and it is worth mentioning some of the most successful prototypes. The German Space Agency DLR has developed the MIRO surgical system [61], whose fast dynamics could allow beating-heart interventions. It has been designed to achieve the requirements of a broad range of surgical applications in endoscopic and open surgery. Integrated multimodal sensors and different control modes allow system configurations for telepresence (Fig. 1.11).

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Fig. 1.11

The MIRO surgical system (courtesy of Deutschen Zentrums für Luft- und Raumfahrt [DLR])

Force feedback is implemented in the Surgeon’s Operating Force-feedback Interface Eindhoven (SOFIE) robotic system, developed at the Eindhoven University of Technology. The arms are mounted on a single frame, which is attached to the patient table [62].

The RAVEN robot (Fig. 1.12) is a surgical system developed specifically for laboratory research. It was developed in the BioRobotics Laboratory at the University of Washington as a cable-driven arm that duplicates the kinematics of the da Vinci robot and can use the da Vinci instruments. With the support of the National Institutes of Health (NIH), eight robots have been built and distributed. To support development and distribution of the RAVEN robot, Applied Dexterity (Seattle, WA) was founded in 2013 [63].

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Fig. 1.12

The Raven II surgical robot (courtesy of Applied Dexterity)

The Surgenius robot (Fig. 1.13) was developed by the company Surgica Robotica (Verona, Italy) in 2010 under license from JPL-NASA of the RAMS system. The robot addressed some of the shortcomings of the da Vinci system, such as its monolithic structure, high cost, and lack of force feedback. The robot received European CE certification in 2013 [64].

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Fig. 1.13

The Surgenius surgical robot (courtesy of Prof. Paolo Fiorini, University of Verona)

Automation-aided surgery was demonstrated by Davies [42] and Rovetta [43] during TURP interventions and in automatic needle placement [65], and the interest in automation is increasing because it could implement the concept of solo surgery in which the functions of the assistant surgeon are replaced during surgery by a robot, so that the main surgeon can operate on his or her own [66].

Some Commercial Surgical Robots

Besides the best-known da Vinci robotic system, other commercial robots are available on the market for a number of surgical applications. Minimally invasive surgery is targeted by Titan Medical Single Port Orifice Robotic Technology (SPORT), which relies on a single incision and expendable flexible tools [67]. The Advanced Laparoscopy through Force refleCT(X)ion (ALF-X) robot is an advanced laparoscopic system that uses a modular configuration of several mobile robots positioned around the operating bed [68]. Of a completely different scale is the Renaissance system for spine screw positioning, by Mazor Robotics. The system mounts directly on the patient’s spine, thus automatically compensating for respiratory motion and ensuring very high position accuracy [69]. Medrobotics Corp. is using the concept of a snake robot to develop its robotics product Flex, targeting interventions in the oral cavity. They achieved approval for Europe in 2014 and aim for a first limited commercial launch on selected European markets [70].

There are several commercial robots for radiation treatment. The CyberKnife is composed of an industrial KUKA robot carrying a linear accelerator as the radiation source. The patient is placed on a bed that can move to compensate for breathing, and the target is tracked by markers placed on the patient’s body. The system can target the tumor with 0.2 mm accuracy, and the overall treatment precision is better than 0.95 mm [71]. In the Novalis system, the radiation source is constructed in an L shape and can rotate around the patient along a horizontal axis [72]. The Gamma Knife system consists of a half sphere, which houses the fixed radiation source and moveable focusing mechanism. The patient’s head is fixed to a stereotactic frame and placed on a moveable bed in the center of the sphere. Through the movement of the bed and the focal adjustment, tumors can be targeted very precisely [71].

Robots for orthopedic surgery are represented by ROBODOC and the RIO Robotic Arm Interactive Orthopedic system. Since 1994, ISS has sold about 80 ROBODOC systems across Europe and Asia. In 2008, ROBODOC was acquired by Curexo Technology Corporation and was FDA-approved for automated bone milling. ROBODOC was rebranded to Curexo ROBODOC in 2007 and to THINK Surgical in 2014 [73]. The RIO system by MAKO Corp. consists of a moveable base and a robotic arm on which a milling tool is mounted. It uses image guidance to control the milling tool mounted at the end of a robotic arm, but it leaves the actual milling to the surgeon, creating resistance on predefined boundaries. MAKO was acquired by Stryker in 2015 [74].

The ARTAS is a robotic system for hair follicle harvesting. A robotic arm carries the harvesting tool, containing a camera and the extraction needles [75]. The camera captures the hair positions, and the control program computes the harvesting pattern for evenly thinning out the hair. The system can adapt to patient movements during the procedure, but the harvested hairs must be implanted by the surgeon by hand.

Some Basic Concepts and Terminology

The official definitions of robot come from the Robot Institute of America (RIA) and the ISO standard (ISO 8373:2013 Robots and robotic devices—Vocabulary): A robot is an actuated mechanism programmable in two or more axes with a degree of autonomy, moving within its environment, to perform intended tasks. The key elements here are the axes of motion, also called degree of freedom (dof) of the robotic structure and degree of autonomy. This last term is not defined in the standard, and it is left to the developer to define how much autonomy a robotic device has. In the case of robotic surgery, the level of autonomy is very low, and the surgeon is always in charge of the motions of the robot. Autonomy in robotic surgery is used in a protective way—for example, to force the surgeon to follow the right cutting path, as in the RIO orthopedic robot, or to keep the joystick masters aligned with the instrument tools, as in the da Vinci system. The capability of limiting the surgical tool motions to avoid delicate areas or to enforce a prescribed path is called a virtual fixture, and it has been proved very useful also in robotic surgery training. Surgical robots consist of a slave station, located at the bedside, and a master station, where the surgeon inputs the motion commands to the robot.

Many books describe the mathematical and physical foundations of robotics [76]. Here we give a very brief summary of the main concepts. The key element in a surgical robot is the surgical instrument, which allows an intervention to be performed under the surgeon’s guidance. The most sophisticated robotic instruments are those for robot-assisted minimally invasive surgery (RAMIS) procedures, which are endowed with several dofs in position (they can move linearly in the X, Y, and Z directions) and in rotation (the distal end of the instrument can rotate around one or more axes). The linear dofs determine the position of the instrument’s distal end, and the rotation dof determines its orientation. Furthermore, the distal end carries the surgical tool (gripper, scissor, hook, etc.) to interact with the tissues, and the tool has its own dof (such as opening and closing of the gripper). A dof of a robot is also called a joint; the part connecting two adjacent dofs is called link. The distal end of the surgical instrument is called the wrist of the instrument, as its articulation is similar to a human wrist.

The number and the configuration of the robot axes determine the kinematic structure of the robot. For example, the instruments of the da Vinci robot have seven dofs, three of which refer to the linear motion of the instrument tip, three to the rotation dofs, and one to the opening and closing of the instrument tool. This number of dofs is computed by adding the number of dofs of the instrument, typically three, with the number of dofs of the supporting arm, typically six, and by subtracting the number of constraints imposed by the fixed pivot point, typically two. The number of dofs of the robot and their range of motion determine the work space of the robot—that is, the volume that the robot or the robotic instrument can reach. The position and orientation of the instrument tool are measured with reference to a coordinate system that permits the instrument position and orientation to be related to the position and orientation of the master joysticks. The robotic system measures the motion of its arms, both master and slave, by using sensors located in the robot joints, and moves the joints with actuators (typically electrical motors), which are coupled to the joints by a transmission system, cables, or gears, to reduce the motor speed and to transfer the motion to links far away from the motor, as in the case of the surgical instruments.

Surgical robots for minimally invasive surgery are teleoperated systems, in which the robot follows the motions of the master joysticks handled by the surgeon’s hands. This control paradigm is different from how industrial robots are controlled; they are programmed in advance, and all their motions are repeated over and over. This type of control is called position or kinematic control , in which the robot reaches the commanded position in spite of obstacles on its motions. This can be a potential safety risk because the robot can damage its surrounding environment if it is given a wrong command. An alternative control method is force control , in which the robot is commanded to exert a given force to the environment. If the robot is not in contact with an object, this command makes the robot move in the direction of the desired force. When a contact is detected, the contact force is limited by the force commanded to the robot. This control mode is more complex than position control because it requires the use of contact sensors. In the case of surgical robots, there are no instruments yet equipped with contact sensors, and the master station is not capable of force feedback. That is, the interaction force between the instrument and the environment is not transmitted to the surgeon commanding the robot. The interaction between the surgeon and the master station that uses forces is called haptics. A different control approach is when the surgeon holds the surgical tool directly, as in the RIO orthopedic system. This control method is called hand-on compliant control, and the robot prevents the human from making wrong motions. In this case, the master and the slave stations are the same, as the surgeon commands the robot by directly moving the robot instrument. Instability can happen in certain situations, for example, when there is a delay between the master commands and the slave motions, and is obviously a dangerous situation that must be avoided. Suitable control algorithms have been designed to avoid these forms of instability but they are not used yet in clinical practice.

To analyze the motions of the robot, to train surgical students, and to plan difficult interventions, surgical simulators can be used. The simulator can represent a general anatomy or a patient-specific anatomy derived from preoperative images of the patient. The simulator can be physical or virtual, meaning that the anatomy is represented by a physical object or by a computer program visualizing anatomical images on a display. These computer simulators are often called virtual reality simulators and may give the user a three-dimensional perception of the anatomy using a stereo display. However, most virtual reality simulators lack the ability to reproduce contact forces, because the biomechanical properties of the tissues are hard to estimate. Furthermore, a simulation that computes the contact forces and the deformations of the simulated organs is very computation-intensive, so it may not display images and render forces in real time. Force feedback and accurate biomechanical simulations are the next frontiers of surgical robotics.

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© Springer International Publishing AG, part of Springer Nature 2018

Yuman Fong, Yanghee Woo, Woo Jin Hyung, Clayton Lau and Vivian E. Strong (eds.)The SAGES Atlas of Robotic Surgeryhttps://doi.org/10.1007/978-3-319-91045-1_2

2. Robotic Operating Rooms

Jeffrey Berman¹  , Emile Dajer¹ and Yuman Fong²

(1)

Jeffrey Berman Architect, New York, NY, USA

(2)

Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA

Jeffrey Berman

Email: [e-mail]

Keywords

FGI guidelinesBuilding codes

Operating rooms (ORs) have been developed to provide a sterile environment in which to perform invasive procedures on patients. ORs are contained in suites that provide sterile support instruments and supplies necessary to perform the sterile procedures in a restricted environment, limiting access by the public and others not trained in or not involved with the procedures. Over the years, many new technologies to assist or augment surgeons have been added to ORs. The recent popularity and ubiquitous presence of robots in this environment raises complex design and planning issues worthy of consideration.

The Development of Robotic Systems

After the development of manually operated laparoscopic tools and instruments, machines that could operate these instruments with different physical abilities from the human hand (i.e., robots) were developed. These robots can be organized into several categories, including guidance systems, high-accuracy manipulators and scaled motion devices that incorporate enhanced vision, and other guidance systems such as magnification with stereo depth of field viewing, image guidance using X-rays and other devices, or navigation based on anatomical landmarks or fiducial markers. These robots seek to perform work not easily accomplished by hand and not accessible to manually operated or manipulated instruments or to assist with work in a difficult or hazardous environment.

Early in the adoption of robot-assisted surgery, robots were generally mobile, stand-alone instruments and systems, which were wheeled into general ORs to assist with parts of various specialized surgeries. These robots finally became the principal operating tool in many complex surgeries. As both ORs and robots have become more sophisticated, it has become functionally critical for these rooms to be designed specifically for the integration of the robotic system with the other video and integration systems incorporated within a modern surgical/interventional environment.

Space Requirements

As defined by the Facility Guidelines Institute (FGI; 2010, 2018), an operating room (OR) is a room in the Surgical Suite, designated and equipped for performing invasive procedures that require a restricted environment [1]. A restricted environment is a designated space with limited access eligibility. Such space has one or more of the following attributes: specific signage, physical barriers, security controls, and protocols that delineate requirements for monitoring, maintenance, attire, and use. The term is generally applied to operating rooms and the suites within which they are contained.

A surgical suite is defined as a space that includes operating rooms and support areas [1].

Our robotic surgical OR would be part of this suite, and we would expect these procedures to be performed under anesthesia in a Class C OR [1].

The design of an OR to support robotic procedures must first start with a basic OR to support any type of general or specialized surgery. The size of these rooms now starts at the code-prescribed minimum of 400 square feet, with dedicated space within the room for sterile surgical instruments, circulating nurses, doctors, desk and charting, and space for anesthesiology, including the anesthesia machine supplies and medicines [2]. These basic functions, as well as circulation around the sterile field and space for instrument and supply carts and bins for trash and other used materials, reside in the 400 square feet [2]. To add a robot or another large piece of equipment to this room while maintaining proper circulation, sterile field, and functionality requires the addition of a substantial amount of square footage, not less than 200–300 addtional square feet . Figure 2.1 shows the physical footprint of a typical OR and the footprints of a typical robotic system and other support systems equipment. Often more than one of these machines is used in the same case, requiring even more room for logistics, movement, and equipment during the procedure and staging prior to and after the use of each system. Figure 2.2 shows the actual sizes of these machines when parked and the additional space required to operate with the equipment in and around the surgical fields. Note the operator space required and the additional circulation space required to maintain the sterile fields.

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Fig. 2.1

Plan of a typical operating room (OR) layout for open or minimally invasive surgery (MIS), with three staff work desks with computer and a picture archiving and communication system (PACS) station and dedicated space for anesthesia and medicines. When all personnel along with fixed and movable equipment is included. An area of 550 square feet is reasonable—slightly larger than the 400 square feet minimum space required by the Facility Guidelines Institute

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Fig. 2.2

A Da Vinci® robot (Intuitive Surgical; Sunnyvale, CA) with two consoles, circulation, setup, and operation requires a minimum area of 140 square feet, increasing the size of the OR by approximately one third

Critical dimensions and clearances are similar to those required in a general OR. These have to do with circulation around the table, maintenance of the sterile field, sterile zones to lay out and prepare instruments, and circulation patterns to, from, and around the field. In robotic surgery, space is also required for the consoles that operate the robots and other equipment related to the controls in the video distribution of the robot images. The size of the expanded surgical workspace at the table pushes the circulation space further from the field and increases it substantially (Figs. 2.3 and 2.4).

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Fig. 2.3

This arrangement is designed to leave the consoles permanently parked near the surgeons’ desks in the corner and to minimize the travel of the robot within the room during setup. The robot is shown parked when not in use. Additional space in the room allows the OR to be used for other procedures when the robot is parked

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Fig. 2.4

This diagram of a robotic OR shows work zones for different functions during setup and during surgery

Typically, a substantial amount of time is required for the robot to be set up and draped and have the necessary instruments installed on its arms. This procedure should take place while the patient is being brought into the room and prepared for the procedure. These two operations need to be separated, as the instruments must be handled in a sterile environment with no through traffic, both to protect the arms of instruments from mechanical damage due to impact and to maintain the sterile field when the instruments are placed and the arms are draped prior to the case. The zone for preparation of a robot should be specifically related to the way it will dock to the patient and the OR table once the case starts. The less movement required to bring the robot into position, the better: The robots are hard to drive when unfolded, and the extension of their large and delicate arms for surgery makes complex movement difficult.

Support and Infrastructure Beyond the OR

Spaces for program support, training rooms, and operational support areas have a major impact on the design of new ORs. These areas must be provided for when planning a new OR suite, or identified and implemented within the building when retrofitting existing ORs for robotics or adding a robotic surgery program to an existing facility, even where the changes within the ORs are minimal.

Ancillary support space is significant in terms of space and resources required to support a functional robotics program. The spaces fall into two major categories: support/repair and training.

Support and Repair Spaces

These areas include repair and working space to house additional parts of the system, including consoles, video carts, and robots when not in use in a specific room, if the facility cannot dedicate ORs to robotic surgery or expand rooms with robots sufficiently to provide adequate parking spaces. A repair space is needed outside of the operating rooms, but preferably on the same floor as the ORs and in the restricted corridor. In this space, systems can be set up for testing and taken apart over time to be repaired and serviced without leaving the area. Hallways and doorways between service areas, storage areas, and ORs should be carefully planned to facilitate movement of these large, heavy instruments without damage to the building or the robot.

The additional instruments and specialty tools required to support the robot will require special processing in a sterile environment, generally a central sterile processing department. Additional storage space for this inventory, instruments, case carts, and supplies must be available in a sterile core adjacent to the robotic operating rooms. These resources are specific to the robot; a full complement of general surgical instruments and supplies will always be required to manually support the procedure and to assist and supplement the robot’s capabilities.

Training Spaces

The training requirements for staff require space to develop skills and test new procedures using simulators, dry lab and wet lab training and experimentation. This training can be performed as part of a comprehensive surgical skills center, or it can be located in another simulation and training center. Facilities can be developed with the ORs and be proprietary to the hospital, but often training is provided on a contract basis in schools or at other dedicated surgical training and simulation facilities that are available to rent on a class or project basis. Workflow and support between these training and education functions and the actual support of surgery need to be carefully coordinated because of the great expense and difficulty of moving robots between distant facilities and the scheduling conflicts that arise between surgery schedules and training classes. The actual robots used for surgery must be available for training and testing in the OR suite at prearranged times.

Case Study: Modification of ORs for Robotics

An interesting case study that illustrates many of the issues involved with integration of a robot into a surgical environment is a project we completed in 2016 at the Josie Robertson Surgery Center in New York City. The hospital had extensive experience with robotic surgery on its inpatient platform and was building a new ambulatory surgery facility. The initial goal for design was to build three dedicated special OR suites over three floors: 1 for robotics, 1 for general surgery and laparoscopic work, and 1 for breast and plastic surgery, for a total of 12 operating rooms, four suites per specialty per floor. The rooms were all constrained to the same size by the footprint area of the new building, and the initial design developed three unique room layouts to support each specialty. What we learned was that there were many common, even identical, elements across the surgical platforms and specialties. These included the staff support spaces such as desks, computer workstations, charting, anesthesia, medicines, supplies, instruments, and communication systems. The patients and all the other elements remain the same size. What changed was the circulation in the room, the logistics and workflow around the surgical field to provide instruments and to service the robot. Space for the robot and all of its ancillary and support equipment is substantial when compared with the overall footprint of a general surgery OR (Figs. 2.5 and 2.6).

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Fig. 2.5

A view from the restricted corridor door, looking at the robot parked against the wall with the consoles

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Fig. 2.6

A robot ready to be prepared for a case. The view is from the position of the anesthesiologist. The door to the sterile core is visible on the right. The consoles are on the left

The major change or difference between a more traditional OR and a robotics room is the additional space needed for the setup of the robot and multiple sterile fields and the more restrictive requirements for circulation and flow of the room. The additional space is not just for the robot. The size of the sterile field also expands significantly, both during room setup and during the case, because the robot will occupy the space normally taken by the instrument table during surgery. A separate area for the instrument table away from the field and a sterile setup prior to the case away from the table are required. The space between the instrument table and the setup area for the robot is significant and falls in a critical area immediately adjacent to the table at the foot and to one side of the patient (Fig. 2.7).

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Fig. 2.7

A robot ready to be draped and have instruments installed on its arms. This occurs at the foot of the table so that the patient can be prepped at the same time. Circulation is around the back of the robot during this period to protect the arms of the robot, the sterile field, and the instruments

When the robot is not in use, it can be parked out of the way of other procedures. The surgical staff appreciated the extra space for supplies and case carts when the robot was not in the room (Fig. 2.8).

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Fig. 2.8

An optional position of the robot in relation to the table for certain procedures that require the table to be shifted laterally to leave clear the aisles along the sides of the field, with adequate space behind the robot

Cabling between the parts of the robot needs to be managed carefully. These cables are heavy and delicate and interfere with both staff walking and cart and supply traffic into the room and to the sterile field, the work area, and the robot. The options for managing and routing these cables are currently limited, and it is important in planning and equipping these rooms to protect them from damage and to prevent the staff from tripping.

Lighting design for these rooms is very similar to that of a traditional or laparoscopic operating room: the general lighting needs to be bright enough for the setup and cleaning of the room as well as the repair and maintenance of the equipment. This lighting also needs to be dimmed so as to not produce intereference with the main surgical light which is designed to provide accurate color rendering of organic tissues and eliminate shadows caused by physical interference between light and patient. The surgeons at the robotic consoles have separately controlled and dimmed lighting overhead in order to control any glare preferentially. All the lighting must be dimmable, and controls must allow the room to be minimally lit to allow circulation between work areas around the robot and the surgical field without glare on the screens. The surgical lights often can be used as task lighting when they are not needed for surgery, but detailed consideration of task lighting requirements for the instruments, the circulating nurse, and the anesthesia work area is critical to the ability of staff to operate equipment and chart the case [3].

The fact that the surgeons are not working in the sterile field but instead are at remote consoles provides opportunities and challenges and raises a series of questions that need to be answered early in the planning and design of the rooms. The major question is whether the consoles should be in the OR or separated from the OR to provide isolation and concentration for the surgeons. The general consensus is to provide console space within the ORs and adjacent to workspace for the surgeons, including the medical record computer and picture archiving and communication system (PACS) terminals used in reviewing the case and preparing for the surgery. This workspace and the consoles should be located away from the surgical field and away from the sterile work zone between and including the circulating nurse desk access to the sterile core and the sterile setup zone between the instrument table, the surgical table, and the front of the robot where instruments are put on and the arms draped before beginning the case.

The expansion of the sterile field poses some interesting opportunities as well as challenges in the layout of the organization of the room and the workflow. Sterile work areas can be consolidated with their circulation and access to the instruments and supplies; the less sterile traffic of trash, in and out room cleaning, traffic from surgeons and others prior to the case, and the arrival, preparation , and departure of the patient can be segregated in a separate area (Figs. 2.9, 2.10, and 2.11). These layouts can yield a more efficient workflow with reduced setup and turnaround times between cases, as well as better infection control and less damage to instruments and parts of the robot. Another part of the basic plan should be dedicated robot rooms with parking space and permanent space for the non-moving parts. Better outcomes result when moving of equipment is minimized between cases and in the setup of cases.

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Fig. 2.9

During setup, preparation, and between cases, work areas are distributed around the room and separated to minimize disruption of independent tasks necessary to begin the surgery. There is more traffic in and out of the OR, and the sterile areas and paths are extended to prepare multiple functions

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